Journal of Emergency Medical Service (JEMS), February 1996Doug Wolfberg

Lights, Sirens and Liability

I'm going to begin this column by stating a bias up front: I believe that lights and sirens are overused by EMS providers. I also believe that light-and-siren use probably causes more deaths and injuries than it saves or prevents. Moreover, light-and-siren use leads to careless driving by overexcited drivers and is one of the most insidious contributors to EMS liability. In this month's column, I am going to construct an argument for the serious curtailment, if not complete abandonment, of light-and-siren use by EMS vehicle operators. This argument will be based on scientific literature, case law and personal observations. I'll start with the personal observations.

I'm the first to admit that the prospect of being able to play with lights and sirens was a big part of the appeal of getting into EMS, but that was when I was a teenager. I came to outgrow the excitement generated by lights and sirens. As time progressed, I realized that working in EMS was more about providing quality patient care, having compassion for the sick and injured, and obtaining as much training and education as I could to become the caregiver I was capable of becoming.

Throughout my 15 years in EMS, I began to more closely observe the effect that lights and sirens could have on an emergency response. While the use of lights and sirens may have gotten me to my destination a little more quickly, I realized that light-and-siren use itself causes dangers. I witnessed instantaneous panic reactions among automobile drivers who, after being approached by a fast-moving ambulance with siren yelping and lights blazing, didn't know whether to stop, swerve, pull over or just keep going. Many such drivers became hazards to themselves, to other vehicles, and to the EMS crew and patient. Moreover, excessive siren use can be a real annoyance to residents who live in the vicinity of your station. This annoyance can hurt public relations and fund-raising, as well as prompt angry residents to petition your town council for a noise ordinance restricting siren use in the vicinity of the station or at certain times of the day.

My Ambulance Crash

In 1985, I was involved in an ambulance accident while responding "Code 3" to a respiratory arrest on the Penn State campus, where my driver made a sudden right-hand turn from the left lane and was struck by a vehicle, the driver of which said she had been sure we were going straight. Although not seriously injured, the driver was cited by the police for failing to yield to an emergency vehicle. I felt bad for her, because I could tell she had panicked when being suddenly confronted by an ambulance in light-and-siren mode. I also believe, because of my driver's indecision in making a sudden right turn, that the driver of the car reasonable assumed she would be clear of us by proceeding forward.

Although I felt bad for the other driver, I reasoned that we were operating an ambulance, with appropriate warning devices, and after all, she failed to yield. Still, I never again felt quite right using lights and sirens so casually. Incidentally, the call to which we were responding was nothing close to respiratory arrest; I seem to remember it was a co-ed with bronchitis. If only we had medical priority dispatching!

There are many studies and cases pertaining to light-and-siren use that support what I have intuitively felt since that day in 1985. That is, we may be doing more harm than good by using lights and sirens. Moreover, we risk enormous liability in the event of an ambulance crash, and I believe that the free use of lights and sirens enhances this risk.

The Data

In 1995 study published in the Annals of Emergency Medicine (1), researchers concluded that transport time from the scene to the hospital in a small city was 43.5 seconds faster with lights and sirens than without. While this difference in transport time was found to be statistically significant, it was not clinically significant. That is, the ambulance may get to the emergency department 43.5 seconds faster by using lights and sirens, but there is nothing the ED staff can do with that extra 43.5 seconds to improve the patient's outcome. These few extra seconds pale in comparison to the well-documented risks of running with lights and sirens. One study found that an ambulance involved in a fatal crash was twice as likely to be running in emergency mode than not (2). An article concluded that "the siren is an extremely limited warning device," and another that its use can cause potential health hazards, including hearing loss (3,4). Still another study concluded that lights and sirens can even have a negative effect on the patient and his or her family members (5).

Steve Forry, EMS specialist for one of the largest insurers of emergency service organizations, the Glatfelter Insurance Group, which runs both Volunteer Fireman's Insurance Services (VFIS) and Ambulance Insurance Services (AIS), said that insurance rates reflect this data. By far the biggest payouts AIS makes under its EMS policies are for crashes in which an ambulance, using red lights and sirens, proceeds through an intersection against a red traffic signal, Forry said. In fact, among volunteer EMS organizations insured by Glatfelter, for every medical malpractice claim against an EMS provider, there are 25 claims for automobile liability arising from ambulance crashes. On the commercial side, the ratio is seven auto claims for every one medical malpractice claim. Thus, it seems as if the way we drive has more of an impact on our insurance rates than does the way we provided patient care. If we're so comparatively careful with our patients' well-being once they're in our ambulance, why are we so recklessly indifferent about the well-being of others when we're blowing a red light at an intersection to save a few insignificant seconds? This seems to be the situation in many of the cases that popped up during my legal research on this subject.

The Case Law

There are dozens of cases where red-light-and-siren ambulance crashes have landed the emergency vehicle operator in court. In a 1994 Connecticut case (6), an ambulance owned by the Fitzgerald Ambulance Service was transporting a patient to Yale New Haven Hospital with its lights and siren activated. As the ambulance crossed an intersection against the red light, it collided with another vehicle. The ambulance service asserted in its defense that the patient's wife, who was riding as a front seat passenger, saw the oncoming vehicle immediately prior to the collision, and was negligent for failing to warn the ambulance driver of what she saw. Not only did this "offensive" defense fail, but Iâm sure it made for pretty bad public relations.

In a 1992 Nebraska case (7), a volunteer operating a city-owned ambulance proceeded through an intersection against a red light and collided with a fully loaded dump truck and the driver of which had the windows rolled up, the air conditioning on and the AM/FM radio playing, and did not hear the ambulance's siren. The trial court found that the ambulance operator briefly slowed down, made a cursory inspection of the intersection, and then accelerated rapidly through the intersection. The ambulance operator was found to be negligent, and this, his service was liable, in part, for the plaintiffâ injuries. The appeals court, in upholding the verdict, noted sternly that although the ambulance "had the right-of-way despite the red light, (the statutory) duty of care·implies that drivers of emergency vehicles cannot simply careen through intersections oblivious to conditions around them. (7)"

In this case, the court discussed the fairly typical statutes that govern the use of lights and sirens, and privileges that emergency vehicle operators enjoy. For instance, ambulances operating lights and sirens are privileged to exceed posted speed limits and enter intersections against red lights if done safely (8). The emergency vehicle operator, despite this privilege, is still under a duty to drive with due regard for the safety of others. In some states, ambulance drivers (I know this is a taboo term-but it fits here) enjoy a form of "good Samaritan immunity" or, if a member of a municipal or public service, "government immunity," when operating an emergency vehicle. However, if a plaintiff can demonstrate that the emergency vehicle operator was grossly negligent or reckless, these immunities provide no protection. This level of negligence or recklessness may be shown by a simple failure to apply the brakes in the intersection, by rapidly accelerating after a cursory slowdown, by traveling in improper lanes of traffic or a host of other ways. It appears as if immunity statutes offer far less protection in collision situations than they do in cases of medical negligence. In addition, some state laws offer only qualified privileges to emergency vehicle operators. For example, in New Jersey, ambulances cannot forcefully take the right of way; other drivers must voluntarily relinquish it (10). Thus, lights and sirens in some states are merely a way to make a polite request to other drivers to yield and do not relieve the emergency vehicle operator of the responsibility to drive carefully.

Recommendations

Far be it from me to flail about on a subject so sensitive without offering a few suggestions to conclude. These thoughts are directed at providers, insurers and regulators, and weâll move up the ladder accordingly.

Make voluntary changes at your service level. The best way to solve the safety and public relations problems relating to light-and-siren use is to start within your own walls. First, accept that the use of warning devices does not improve patient care or outcomes. Second, recognize that warning devices cause danger and liability. Third, revise your standard operating procedures and, with medical input, your protocols. Fourth, train your personnel that warning devices should be used only in the most extreme emergencies (11) and that lights and sirens donât replace brains and eyes when driving.

Demand better dispatching. There is no reason why we should accept bogus dispatch information that unnecessarily fuels adrenaline surges. Adequately trained dispatchers should be able to determine the severity of the call and recognize that most are not life threatening. Though we're never sure what to expect while responding, we know what we're dealing with once we've reached the scene. Thus, restrictions on light-and-siren use should be even more stringent when transporting the patient to the hospital.

Insurers, get involved! Remember how we used to ride on tailboards? Well, ever since the insurance industry cracked down on this practice, it has been seriously curtailed (though, of course, it still occurs). Insurers should likewise demand adherence to common-sense protocols governing light-and-siren use. Moreover, insurers should use their tremendous resources (as VFIS does) to offer driver training, sample response guidelines and other risk-management information.

Devise voluntary standards. National standards-setting organizations, whose product often are followed closely by emergency service organizations, should get into the act and make bold statements on the overuse and dangers of warning devices.

If all else fails, pass new laws or promulgate new regulations! State EMS agencies should not shirk their responsibility to protect the public safety when it is placed at risk by EMS providers. State regulations should substantially curtail light-and-siren use if other avenues fail. Moreover, state legislatures should remove the statutory requirements that lights and sirens must be operating for emergency vehicles operators to enjoy any immunity for possible acts of negligence. I realize that few legislators would ever vote for a bill restricting light-and-siren use, especially in the face of anger from volunteer constituents. However, the data, the case law and our insurance rates all show that we are dealing with an expensive public safety and liability problem in excessive light-and-siren use.

In conclusion, EMS providers are public safety personnel who are intimately involved in the maintenance of the public health. This responsibility transcends the patient in the back of the ambulance. It extends to our communities, fellow pedestrians and vehicle operators. The evidence suggests that free light-and-siren use ill serves these responsibilities.